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47
Remarks.—80 per cent. of these cases began below 7 and 67 per cent. below 5; of the spine cases
72 per cent. below 5 ; hip cases 64 per cent. between 2 and 6; of the others there was fairly even
distribution over the first nine years of life.
(1) Tuberculous Disease of the Spine. In the large majority of these cases the
onset of the disease was quite early in life ; in 72 per cent. between the second and fifth year. It is not
possible to ascertain with accuracy the presence or absence of active disease without watching the child
for several weeks, and hence no good estimate of the proportion with active disease could be made;
probably it is, however, not more than 10 per cent. to 15 per cent. There is a great tendency
to recrudescence in cases of caries of the spine which may for a long time have been quite quiet, and
many of the children have other foci of tubercular disease. In 186 children there were 8 with hip
disease, 7 with lung disease, and 8 with other tubercular disorders in joints, skin, or glands.
Excluding 4 cases in which there was no sign of disease, past or present, and 2 in which the diagnosis
was extremely doubtful, the classification of the 180 remaining cases, as regards deformity or
complications, was :—
Slight angular deformity 35
Moderate angular deformity 41
Severe angular deformity 104
History of past paraplegia 19
Present or past abscess 50
The severity of the deformity depends (i.) on the portion of spine affected ; the upper dorsal
region is far more likely to be the seat of severe deformity than are the lumbar or the cervical regions ;
(ii.) the efficacy of the early treatment; if all the cases could be diagnosed early and the children kept
fixed in a recumbent position for a sufficient length of time, amongst good hygienic surroundings, the
cases with severe deformity would practically disappear.
Paraplegic cases are not as a rule admitted to the schools. Of the 19 cases of paraplegia, 16 had
completely recovered, and three had partially recovered and were still improving, the only case seen
of a spinal paraplegia which was still complete, had resulted from a fracture of the spine and not from
caries. These cases seem to illustrate the very good prognosis of paraplegia in spinal caries in children,
prolonged treatment in recumbency leading almost certainly to complete cure. In only one ca6e had
laminectomy been done, and in this, gradual recovery had resulted some months later, the result of rest
rather than operation.
(2) Tuberculous Disease of the Hip-joint. Tubercular hip disease is evident at a
slightly later age than spinal caries, but 64 per cent. of the cases appeared between the third and sixth
years. Allowing for seven bilateral cases, a total of 210 affected hip-joints could be classified as follows ;—
Quiescent, with good mobile hip 14
Good functional result with ankylosis 22
„ „ „ with some mobility 20
Moderate functional result 34
Bad functional result (including 25 excisions) 71
Active disease 36
Amputations 6
7 cases could not be fully examined owing to the mode of fixation in splints or plaster.
The separation into good, moderate, or bad functional result was made by noting the degree of
fixed flexion and adduction deformity, and the amount of apparent shortening, i.e., the preventible
deformity, as distinct from the real shortening, which is due to destruction of bone and is not preventible.
Thus a hip which was ankylosed in a good position with two inches of real shortening would be classed
as a good result, whereas one in which there was only one inch of real shortening, but 30 deg.each of fixed
adduction and flexion, leading to an additional apparent shortening of 2½ inches, would be classed as a
bad result. Most of these bad results might have been avoided had it been possible to keep the child
recumbent for a long period, with an extension applied to the hip in the adducted position. Many of
them might still be improved by active surgical treatment, by weight extension, or by osteotomy ; in
only ten cases out of the 210 was there evidence that an ostectomy had been performed. The 25 cases
in which excision of the hip had apparently been carried out were all classed as bad functional results.
In none of them was the disease still active. Excision of the hip is a severe operation which seems to
mend or end the disease. It invariably results in a dorsal dislocation of the stump of the neck of the
femur, and by thus removing pressure from the acetabulum enables any remaining disease there to
undergo cure. A child, on whom an excision of the hip has been performed, seems, when lying on the
couch, to have a remarkably good joint left, with excellent mobility in all directions, but directly he stands
the dorsal dislocation appears, and he walks most laboriously, the whole body dropping over with,
each step taken upon the weakened limb. He would be much better off with a firmly ankylosed joint
in even a fair position. Evidences of past suppuration were present in 61 per cent, of the cases, and in
two cases unopened abscesses were found. Associated tuberculous disease was present in 12 cases, in
8 of them the spine being the other site of disease.
(3) Tuberculous Disease of the Knee Joint.—The distribution of the age of onset
over the first nine years of life was much more even than in the two previous diseases. f the 83 cases
two were bilateral, giving a total of 85 knees, in 27 of which the disease was active, in 54 inactive, whilst